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MR RECORDS SENT FAX 216. 587. 8043 MARYMOUNT HOSPITAL 12300 McCracken Road Garfield Heights OH 44125 216-587-8224 AUTHORIZATION FOR RELEASE OF MEDICAL SURGICAL OR BEHAVIORAL INFORMATION Patient Name Last First Middle Initial Address Birth Date Phone No City State Zip Code Soc. Sec. No Release Information To Name of Person/Doctor/Hospital I hereby authorize Marymount Hospital to release the health information indicated below that is contained in m.

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